Let’s work together

Name *

First Name

Last Name

Phone *

(###)

###

####

Todays Date

MM

DD

YYYY

Release of Liability *

As the client, and in consideration for my participation in breathwork sessions with Katie Graham LLC and the breathwork facilitator Katie Graham. I agree that my participation in the breathwork is entirely voluntary and that I assume any risk associated with participation. Any actions or lack of actions, taken by me, the client, of such advice is done so solely by choice and responsibility, and any harm, injury, or loss that may occur to me or my property as a result of my participation in the breathwork session, is neither the responsibility nor liability of Katie Graham LLC. I understand that during the breathwork, I may be photographed or videotaped for quality training purposes. We promise to take utmost care of any footage of you and will pledge that this footage will only be used for internal training purposes and not distributed in any way, within the boundaries of the law that applies to this agreement. If for whatever reason we wish to use footage outside of training purposes, we will inform you and get your permission first. By signing this agreement, you agree to these terms. I understand that breathwork is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I recognize that breathwork requires emotional, physical, and mental effort, exertion, and behavioral experimentation, on my part, which may cause physical, mental or emotional injury. I fully acknowledge and take full responsibility for all the risks involved. I understand that it is my responsibility to consult with my health care provider prior to participating in the breathwork session. In the event that I am injured, I agree to assume any financial obligation, either through my personal health insurance, or through some other means, for any medical costs I incur. Katie Graham LLC assume no responsibility for any medical expenses, injury, or damage suffered by me in connection with the use of any facilities or services in connection with the Practicum. IN CONSIDERATION OF MY PARTICIPATION IN THE BREATHWORK, I HEREBY GENERALLY RELEASE, AND PROMISE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS KATIE GRAHAM LLC AND FACILITATOR KATIE GRAHAM, AND THEIR RESPECTIVE AGENTS AND EMPLOYEES (THE “RELEASE PARTIES”), FROM ANY LIABILITY WHATSOEVER. I will reimburse Katie Graham LLC and Facilitator Katie Graham for any damages, reasonable settlements and defense costs, including attorney’s fees, that they incur because of any such claims made against them. I agree that the terms of this agreement, including the indemnification obligations in this paragraph, will be binding on my estate, and my personal representative, executor, administrator or guardian will be obligated to respect and enforce them. This RELEASE does not extend to claims for gross negligence, intentional or reckless misconduct, or any other liabilities that applicable law does not permit to be excluded by agreement. I agree that the purpose of this agreement is that it shall be an enforceable RELEASE OF LIABILITY AND INDEMNITY as broad and inclusive as is permitted by Utah law. I agree that if any portion or provision of this agreement is found to be invalid or unenforceable, then the remainder will continue in full force and effect. I also agree that any invalid provision will be modified or partially enforced to the maximum extent permitted by law to carry out the purpose of the agreement. I understand that this is a contract that affects my legal rights, and I have read and understood this form and all its contents, and I voluntarily agree to the terms and conditions stated above. To submit questions regarding this release please email: hello@katiekaygraham.com

I accept

I do not accept

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

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Have you been hospitalized in the last 12 months? *

Yes

No

Have you had OR do you presently have any of the following conditions? (Check if yes.)

Choose as many as applies

Angina

Cardiovascular disease

Heart attack

High blood pressure

Glaucoma

Retinal detachment

Osteoporosis

Seizure disorders

Recent injury or surgery

Any condition for which you take regular medications

History of panic attacks, psychosis, or disturbances

Severe untreated mental illness

Family history of aneurysms

Frequent dizziness or vertigo

Are you currently pregnant?

Other

If you have answered “Yes” to one or more of the above questions, you must consult your physician before engaging in breathwork. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. *

I understand

I do not understand